About Me

Allison is a registered nurse and senior health policy adviser with some 25 years experience. Prior to launching CPD Nurse Escapes, Allison worked as a private consultant for a diverse range of clients in the government and non-government, health, community and education sectors. Allison has an extensive background in regulation, governance and professional practice and applies this in education, policy development and project management. Allison was the Principal Advisor, Professional Practice at the Nursing & Midwifery Board of South Australia, for 10 years where she was responsible for developing nursing and midwifery policy and standards and advising and educating nurses and midwives on professional practice issues.

Sunday, 20 May 2012

Understanding Nursing Scope of Practice (Part 2)

Most nurses are also clearly
able to self assess what they are competent and what they are not competent to
perform. It is more difficult however to determine what we are authorised to
perform as our professional

One must consider
professional scope of practice in context with changing expectations, practices,
client needs, the changing health care system and the expanding expertise of
the profession.Internationally,
nursing is moving towards a broad, enabling scope of practice. These broader
scopes of practice support health practitioners to make decisions about and
within their competence and the environment/setting in which they practice.

By supporting and
facilitating nurses to make appropriate decisions about their practice, we are
moving away from overly prescriptive policies and procedures that restrict
practice based on historical and cultural practices. We are also moving away
from the need for routine certification of tasks and activities and focusing on
annual continuing professional development and self assessment of own
competence. Individual nurses, as regulated health professionals, should be
able to make decisions about their level of competence to perform specific
tasks and activities, rather than face artificial barriers imposed by outdated
organisational, industry based policies and legislation. In doing so however,
nurses must have a sound understanding of scope of practice decision making to
achieve this.

Challenge…Role Confusion

Nurses cannot make clear and
sound decisions within their scope of practice if they do not understand their
scope and limitations of practice. One of the key challenges is that the
practice of nursing is so broad that an element of role confusion is almost
inevitable. Add to this, nursing is one profession with two levels of
registration, differentiated by levels of accountability and decision making
(not competence). Further there are few nursing tasks or procedures that are
protected practice and are therefore able to be performed by other health professions
and providers, including unregulated healthcare workers. Therefore the tasks
performed by nurses do not distinguish nursing practice from other providers.

Though the title of nursing
is protected by legislation, the practices within our professional aren’t! It
is the roles and responsibilities related to coordinating care and the
knowledge and skills utilised by the nurses determining and providing the care,
that distinguishes the nurse – not the task itself. It is a concern then that
all too often nursing policy is task focused rather than scope of practice
focused and limits the enhancement and expansion of nursing practice.

There are other drivers
however that the nursing professional can utilise to assist them to enhance
their scope of practice and decision making. There is clear support from
government and employers to ensure availability of a cost effective mix of
health services and providers. We have been moving towards health reform
agendas for some year, both at a state and national level. There is an
increasing focus on primary health care models of service delivery, where
nurses excel and are cost effective and efficient.

With the need to refocus
health care delivery in the community (and away from tertiary health care
services) provides an opportunity for nurses to be at the forefront of service
development, design and practice. With these changes there is a need for new
profiles and roles for health care providers and a need to better design roles.Nurse
led primary health care clinics, health promotion and prevention programs, home
visiting, transition from hospital to home. There is also growing expectation
of the public, as healthcare consumers, for improved access to cost effective
health services.Nurses have the
perfect opportunity to expand into these roles.

The Nursing and Midwifery
Board of Australia (NMBA) has endorsed national decision-making frameworks for
both nurses and midwives. These two flowcharts are designed to assist nurses
(and midwives) in their professional decision making through a structured and
transparent process. It also provides the nurse with and an evidence-based
process (approved by the regulatory authority) in their decision-making that
they may use in support/defence of their decisions should they be required to
provide it.

Scope of Practice Principles

In defining Scope of Practice
there are several principles that ensure broad enabling definitions. Scope of
practice frameworks should provide reasonable direction of appropriate
parameters for professional practice. These parameter should clearly articulate
the breadth of the nursing role without prescribing specific tasks or functions
that are self limiting rather than enabling the nurse determine the
appropriateness of their role. Definitions should describe nursing activities,
tasks and functions so as not to inappropriately limit nursing practice or the
ability to meet individual and population needs or preventor to prevent nurses from responding to
individual client or client population needs of from adapting to change.

Scopes of Nursing Practice
must be consistent with national competency and role standards, guidelines and
codes, (ANMC National Competencies and NMBA Standards) and reflect
international definitions of and positions on nursing practice (such as the
International Council of Nurses www.icn.ch)

Finally scopes of practice
should recognise and reflect that nursing is practiced in a diversity of
environments and communities and as such, must adapt to meeting the specific
and unique needs of these settings. Nursing Scope of Practice frameworks should
recognise and acknowledge that nursing is practiced in a broad wide range of
areas, not solely direct clinical care.

The Nursing and Midwifery Board of Australia has
defined “To Practice the Profession” as being:

“any role, whether
remunerated or not, in which the individual uses their skills and knowledge as
a health practitioner in their profession. For the purposes of this
registration standard, practice is not restricted to the provision of direct
clinical care.

It also includes using
professional knowledge in a direct nonclinical relationship with clients,
working in management, administration, education, research, advisory,
regulatory or policy development roles, and any other roles that impact on
safe, effective delivery of services in the profession”. (Fact Sheet
Registration Types AHPRA April 2010).

Scopes of Practice must be
driven by and promote safe and competent nursing practice. They must be
flexible enough to be responsive to change in community/client health care
needs. They must further provide appropriate information to consumers of health
care services to enable them to make informed choices about the nursing care
services they access and receive and to evaluate the practice and standards of
nurses who provide their care.

A Nurse’s decision making
within and about their scope of practice needs to structured and based on a
defined framework, set of guidelines or tool that assists them to make informed
and transparent decisions consistent with the expectations of the profession
and the regulatory authority (Nursing and Midwifery Board of Australia). Any
Scope of Practice tool should support the nurse, and facilitate their thinking
and judgement and guide their decision making process. It can also be used by
individual nurses, to self assess their practice, reflect on their competence
to make appropriate decisions. In particular it enables registered nurses who
are autonomous in their decision making, to assess their critically review
their competence to understand and interpret their scope and limitations of
practice.

SOP
of the Profession

So, is there a difference
between the scope of practice of the nursing profession as a whole and the
scope of practice of individual nurses? In truth our scope of practice is
influenced by so many factors that each individual nurse would have a unique
scope of practice, even as undergraduates, students have difference clinical
placements and are exposed to diverse clinical settings, client groups and
procedures even though they are undertaking the same course. The scope of
practice of the profession is the broadest context of practice, the outermost
limits of professional practice under which all nurses practice.It includes the
broad and diverse range of roles, activities, functions, responsibilities and
decision-making capacity within which all nurses practice. It is informed by
all of the factors that influence (and therefore diversify) our practice and
includes the setting and environment in which we work, the policies and
procedures that we are bound by (both those specific to our employer and those
established by government and the profession), our level of education and
experience, knowledge and skills, professional standards and codes of practice,
legislation, the types of professional judgement and decision-making we are accountable
for and the health needs of the population.

SOP
of the Individual Nurse

The scope of practice of the
individual nurse then is different from that of the profession. No nurse can be
competent to perform all of the range of roles, activities and functions etc.
How then do we know what each of our individual scope of practice is? It is
clearly more specifically defined than the scope of the profession as each
nurse must be able to determine what practices and responsibilities they are
able to undertake. The scope of practice of a nurse is that which they are
EDUCATED, AUTHORISED and COMPETENT to perform.

Nurses must assess these
components relevant to their own practice to determine what is within and what
is outside of their scope of practice.

Most nurses are comfortable
with assessing and articulating their level of education and knowledge. A nurse’s authority comes from a number
of sources and nurses (and employers) are often unclear about what level of
authority is required in different circumstances. One of the most misunderstood
issues in relation to authority relates to the to role distinctions between the
registered and enrolled nurse.

Australian Nursing and Midwifery Council (ANMC) – the
ANMC was restructured in 2011 to become the Australian Nursing and Midwifery
Accreditation Council (ANMAC) and provides accreditation of overseas nurses and
midwives seeking registration in Australia and accreditation of courses leading
to registration as a nurse or midwife. The ANMC Competence Standards are now
available on the NMBA website.

CPD Nurse Escapes

CPD Nurse Escapes provides nurses and midwives with unique professional development opportunities in exciting escape destinations. Go to our new website (currently under development) www.cpdnurseescapes.com